What’s New in the Guidelines for Surgical Ablation …...What’s New in the Guidelines for...
Transcript of What’s New in the Guidelines for Surgical Ablation …...What’s New in the Guidelines for...
What’s New in the Guidelines for Surgical Ablation for Atrial Fibrillation?Vinay Badhwar, MD
Gordon F. Murray Professor and ChairmanDepartment of Cardiovascular & Thoracic SurgeryWest Virginia UniversityMorgantown, WV, USA
Disclosures
No relevant financial disclosures
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Why Perform Surgical Ablation ?
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
AF Definitions
Paroxysmal AF that terminates spontaneouslyor with intervention within 7 d
Persistent Continuous AF sustained > 7d
LS Persistent Continuous AF sustained > 12m
Permanent Joint decision, no effort to maintain SR
Heart Rhythm. 2012;9:632-696STS/EACTS Latin America Cardiovascular Surgery Conference 2017
AF DefinitionsParoxysmal AF that terminates spontaneously
or with intervention within 7 d
Persistent Continuous AF sustained beyond 7d
Early Persistent AF that is sustained beyond 7 days but is less than 3 months in duration.
LS Persistent Continuous AF sustained > 12m
Permanent Joint decision, no effort to maintain SR as a therapeutic attitude and should no longer be used
Heart Rhythm. 2017;S1547STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines
Published SearchCriteria
Systematic Review
Products of Review On-line
COI Resolution
Surgeon and EP Authorship
External Society Review
DefinedConsensus (Modified Delphi)
STS 2017 Yes Yes Yes Yes No No Yes
AATS 2017 Yes Yes No Yes Yes No Yes
ESC/EACTS 2016 No Yes No Yes Yes Yes Yes
HRS2012/2014/2017 No No No Yes Yes Yes Yes
Methodology
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines
2014 ACC AHA HRS Guideline
•Grouped all cardiac operations as a whole•Utilized early surgical ablation data acquired from cases performed between 1998-2005
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines
2014 ACC AHA HRS Guideline
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines2016 ESC Guidelines for the Management of Atrial
Fibrillation (in collaboration with EACTS)
•Similar to 2014 HRS guidelines with respect to concomitant operations
•Important additions of minimally invasive surgery, heart team assessment, experience, lesion set
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines2016 ESC Guidelines for the Management of Atrial
Fibrillation (in collaboration with EACTS)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice GuidelinesNew Assessment Methodology
Clinical Practice GuidelinesNew Assessment Methodology
Clinical Practice Guidelines2017 STS Clinical Practice Guidelines for the
Surgical Treatment of Atrial Fibrillation
•Distinct from 2014 HRS guidelines as separated concomitant operations into specific operative procedures: Mitral Valve, Aortic Valve, CABG
•Weighed in on lesion set based on new evidence since 2016 ESC effort
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines2017 STS Clinical Practice Guidelines for the
Surgical Treatment of Atrial Fibrillation•Distinct from HRS and ESC efforts on weight and ability to define symptoms of AF when patients already going for cardiac operation
•Risk defined by STS database major morbidity•Evidence based options for surgeons in typical clinical scenarios based on mortality, morbidity and 1-year outcome
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 STS Clinical Practice Guidelines
Mitral Valve Operations• Multiple populations studied: 11 RCTs, 4 Meta-analyses,
Several Institutional experiencesRecommendation:
•Surgical ablation for AF can be performed without
additional risk of operative mortality or major morbidity,
and is recommended at the time of concomitant mitral
operations to restore sinus rhythm. (COR: I, LOE: A)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 STS Clinical Practice Guidelines
AVR, isolated CABG, AVR+CABG Operations• Limited populations studied: 2 RCTs, 2 Meta-analyses,
limited Institutional experiencesRecommendation:
•Surgical ablation for AF can be performed without
additional risk operative of mortality or major morbidity,
and is recommended at the time of concomitant isolated
AVR, isolated CABG, and AVR+CABG operations to
restore sinus rhythm. (COR: I, LOE: B-NR)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 STS Clinical Practice Guidelines
Stand Alone Operations• Multiple populations studied: 4 RCTs, 4 Meta-analyses,
Several Institutional experiencesRecommendation:
•Surgical ablation for symptomatic AF in the absence of
structural heart disease that is refractory to class I/III
anti-arrhythmic drugs and/or catheter-based therapy is
reasonable as a primary stand-alone procedure, to
restore sinus rhythm. (COR: IIA, LOE: B-R)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 STS Clinical Practice Guidelines
Stand Alone Operations
Recommendation:
•Surgical ablation for symptomatic persistent or
longstanding persistent AF in the absence of structural
heart disease is reasonable, as a stand-alone procedure
using the Cox-Maze III/IV lesion set compared to
pulmonary vein isolation alone. (COR IIA, LOE B-NR)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 STS Clinical Practice Guidelines
All Operations
Recommendation:
•Surgical ablation for symptomatic AF in the setting of
left atrial enlargement (≥ 4.5 cm) or more than moderate
mitral regurgitation by pulmonary vein isolation alone is
not recommended. (COR: III - No Benefit, LOE: C-EO)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 STS Clinical Practice Guidelines
All Operations
Recommendation:
• It is reasonable to perform LA appendage excision or
exclusion in conjunction with surgical ablation for AF
for longitudinal thromboembolic morbidity prevention.
(COR: IIA, LOE: C-LD)
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines2017 AATS Expert Consensus Guidelines Examining
Surgical Treatment for Atrial Fibrillation
•Aligned with STS Clinical Practice Guidelines with complimentary non-duplicative recommendations
•Important additional clarity provided on mortality, stroke prevention, quality of life, surgical experience, energy source
•Meta-analyses, Forest plot comparisons
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 AATS Expert Consensus Guidelines
(COR: I, LOE: A)
Survival at 1 year and > 1 yearRecommendation:
• It is reasonable to choose to perform a concomitant
surgical ablation procedure for patients with a history of
AF over no treatment of AF because long-term survival
is unaffected or improved by surgical ablation.
• (COR: IIA, LOE: A 1 year, B-NR > 1 year)
2017 AATS Expert Consensus Guidelines
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Stroke
Recommendation:
• It is reasonable to choose to perform a concomitant
surgical ablation procedure for patients with a history of
AF over no treatment of AF because there is no
increased risk of perioperative stroke/TIA.
• (COR: IIA, LOE: A)
2017 AATS Expert Consensus Guidelines
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Quality of LifeRecommendation:
• It is reasonable to choose to perform a concomitant
surgical ablation procedure for patients with a history of
AF over no treatment of AF because there is significant
improvement in Health Related Quality of Life (HRQL)
and AF-related symptoms associated with surgical
ablation for AF.
• (COR: IIA, LOE: B-R HRQL, C-LD AF Symptoms)
2017 AATS Expert Consensus Guidelines
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Experience – Proctored 3-5 cases
Recommendation:
•Training and education should be considered before the
performance of surgical ablation, but the effectiveness
of a training program is unclear. More specific research
needs to be conducted because there have been limited
populations evaluated.
• (COR: I, LOE: C-EO)
2017 AATS Expert Consensus Guidelines
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines2017 HRS Expert Consensus Statement on Catheter
and Surgical Ablation of Atrial Fibrillation•Aligned with STS and AATS Clinical Practice Guidelines with complimentary recommendations
•Important agreement of COR for Surgical Ablation •Distinct from STS and AATS in that HRS retains recommendations based establishment of AF symptoms and medicinal treatment
•However, language of acknowledgement on relevance of symptoms in concomitant operation
Heart Rhythm. 2017;S1547STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 HRS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
Heart Rhythm. 2017;S1547STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 HRS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
Heart Rhythm. 2017;S1547STS/EACTS Latin America Cardiovascular Surgery Conference 2017
2017 HRS Expert Consensus Statement on Catheter and Surgical Ablation of Atrial Fibrillation
Heart Rhythm. 2017;S1547STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Clinical Practice Guidelines Summary•Substantial progress on multidisciplinary collaboration and societal recommendations
•Classification of surgical ablation by operative category: open atrial, close atrial, stand-alone
•Important new knowledge on the impact of surgical ablation on mortality, survival and late morbidity
•Guidelines provide recommendations based on an interpretation of the evidence but do not replace the decision between patient and surgeon
STS/EACTS Latin America Cardiovascular Surgery Conference 2017
Thank You